Please answer this application as completely as possible. Once you submit the application, we will contact you within 2 business days to set-up an interview and complete your registration. Thank you for your interest in the program.
Parent/Guardian
Please complete this section for the primary parent/guardian of the child.
First Name (Required)
Middle Name
Last Name (Required)
Suffix
Birthday (Required)
Gender
Female
Male
Nonbinary
Email Address (Required)
Confirm Email Address
It appears that you have previously submitted an application. If you wish to apply again, please contact us by phone or in person.
Mobile Phone
Opt In for Text Messages
Yes
No
Home Phone
Work Phone
Ext.
It appears that you have previously submitted an application. If you wish to apply again, please contact us by phone or in person.
Race
American Indian or Alaska Native
Asian
Black or African American
Multi-racial/Biracial
Native Hawaiian/Other Pacific Islander
Other
Unspecified
White
Hispanic
Yes
No
English Proficiency
Little
Moderate
None
Proficient
Other Language
African
American Sign Language
East Asian
English
European & Slavic
Middle Eastern & South Asian
Native Central American, South American & Mexican
Native North American/Alaska Native
Other
Pacific Island
Spanish
Highest Grade Completed
Associate's Degree
Bachelor's Degree
College Degree/Training Cert.
College or Advance Training
General Education Diploma
Grade 10
Grade 11
Grade 12
Grade 9 or less
High School Graduate
Master's Degree
Employment Status
Full-time & Training
Full-time (35 hours/week or more)
Part-time & Training
Part-time (Under 35 hours/week)
Retired or Disabled
Seasonally Employed
Training or School
Unemployed
Child's Relationship
Biological/Adopted/Step
Foster
Grandchild
Other
Other Relative
Custody
Yes
No
Address
Is your family experiencing homelessness?
Yes
No
Living Address (Required)
Address Line 2
City (Required)
State (Required)
ZIP (Required)
Click here
to find a provider in your area.
Mailing Address same as Living Address
Mailing Address
Address Line 2
City
State
ZIP
Additional Parent/Guardian
Information about a secondary parent/guardian:
Is there another parent/guardian in the family?
Yes
No
First Name (Required)
Middle Name
Last Name (Required)
Suffix
Birthday (Required)
Gender
Female
Male
Nonbinary
Email Address
Confirm Email Address
It appears that you have previously submitted an application. If you wish to apply again, please contact us by phone or in person.
Mobile Phone
Opt In for Text Messages
Yes
No
Home Phone
Work Phone
Ext.
It appears that you have previously submitted an application. If you wish to apply again, please contact us by phone or in person.
Race
American Indian or Alaska Native
Asian
Black or African American
Multi-racial/Biracial
Native Hawaiian/Other Pacific Islander
Other
Unspecified
White
Hispanic
Yes
No
English Proficiency
Little
Moderate
None
Proficient
Other Language
African
American Sign Language
East Asian
English
European & Slavic
Middle Eastern & South Asian
Native Central American, South American & Mexican
Native North American/Alaska Native
Other
Pacific Island
Spanish
Other Language Proficiency
Little
Moderate
None
Proficient
Highest Grade Completed
Associate's Degree
Bachelor's Degree
College Degree/Training Cert.
College or Advance Training
General Education Diploma
Grade 10
Grade 11
Grade 12
Grade 9 or less
High School Graduate
Master's Degree
Employment Status
Full-time & Training
Full-time (35 hours/week or more)
Part-time & Training
Part-time (Under 35 hours/week)
Retired or Disabled
Seasonally Employed
Training or School
Unemployed
Child's Relationship
Biological/Adopted/Step
Foster
Grandchild
Other
Other Relative
Custody
Yes
No
Family Information
Number of Parents/Guardians
One Parent Family
Two Parent Family
Relationship to Participant(s)
Foster parent(s) not including relatives
Grandparent(s)
Other
Parent(s) (e.g. biological, adoptive, stepparents)
Relative(s) other than grandparents
Primary Language at Home
African
American Sign Language
East Asian
English
European & Slavic
Middle Eastern & South Asian
Native Central American, South American & Mexican
Native North American/Alaska Native
Other
Pacific Island
Spanish
Number in Household
Gross Annual Income
Is your family receiving cash benefits or other services under the Temporary Assistance for Needy Families (TANF) program?
Yes
No
Is your family receiving Supplemental Security Income (SSI)?
Yes
No
Is your family receiving services from WIC?
Yes
No
Is your family receiving services under the Supplemental Nutrition Assistance Program (SNAP), formerly referred to as Food Stamps?
Yes
No
Is at least one parent/guardian an active duty member of the United States military?
Yes
No
Is at least one parent/guardian a veteran of the United States military?
Yes
No
Child (Applicant)
Information about your child
First Name (Required)
Middle Name
Last Name (Required)
Suffix
Birthday (Required)
Gender
Female
Male
Nonbinary
Race
American Indian or Alaska Native
Asian
Black or African American
Multi-racial/Biracial
Native Hawaiian/Other Pacific Islander
Other
Unspecified
White
Hispanic
Yes
No
English Proficiency
Little
Moderate
None
Proficient
Other Language
African
American Sign Language
East Asian
English
European & Slavic
Middle Eastern & South Asian
Native Central American, South American & Mexican
Native North American/Alaska Native
Other
Pacific Island
Spanish
Primary Health Coverage
Combined Medicaid/CHIP
Medicaid
No Insurance
Other
Private Health Insurance
Medicaid Eligibility
Not Eligible
On Medicaid
Potentially Eligible
Doctor/Medical Home
Addison, Clyde MD
Al-Agba, Niran Dr. (Peds)
Bainbridge Pediatrics
Bangor Medical Clinic
Best Dental Help
Brown, Leslie ARNP
Carlson, Todd MD
Caulkins, Robert L (DO)
Chang, Tamara MD
Cheng, Christopher H MD
Cheung, Jason MD
CHI Franciscan Family Medicine
CHI Francisican Health
Chi Fransciscan Belfair
Chow, Jenny MD
Cogley, Catherine MD
Corcoran, Connie L, M.D.
Dr. Ginnie Taylor
Dr. Tolles
Dr. Tolles
Drs Clinic
Fechtner, Chelsea
Fleet and Family Services
Franciscan Medical Port Orchard
Franciscan Women's Health Associ
Harbor Pediatrics
Harrison Health Partners Belfair
Harrison Health Partners Family
Harrison Health Partners Primary
Harrison HealthPartners Primary
Hataula, John M. MD, FAAP
Haynes, Michelle ARNP, MN, CPNP/
Herron, Thomas MD
Hope Central
Jefferson Healthcare Sheridan
Kaiser Permanente Port Orchard
Kaiser Permanente Poulsbo
Kaiser Permanente Silverdale
KCR WIC Bremerton
KCR WIC Port Orchard
KCR WIC Silverdale
Kitsap Children's Clinic PO
Kitsap Children's Clinic Silverd
Kitsap Immigrant Assistance Cent
Kitsap OBGYN
Kitsap Public Health District
Link Audiology
Madigan Army Medical Center
Malone Pediatrics
Miller, Brian
Miller, Sarah PA-C
Multicare Covington
Naval Hospital Pedatrics
Naval Hospital PRENATAL
Neighborcare Rainier Beach
North Kitsap Family Practice
North Olympic Healthcare Network
NW Family Medicine Residency-CHI
Odessa Brown Children's Clinic
Olympia Pediatrics
Olympic Family Practice
Pacifica Medicine And Wellness
Pediatric Clinic at Harborview
Pediatrics Northwest
Peninsula CHILDREN's Clinic
Peninsula Community Health Svcs
Peninsula FAMILY Medical Center
Port Gamble S'Kallam Medical
Poulsbo Doctors Clinic
Puyallup Tribal Healthcare Autho
Ricker, David MD
Rurik, Gregory MD
Salt & Cedar Birth Services
Scholten, Roger MD
Shaw, Lein-Chun
Shelton Family Medicine
Silverdale Pediatrics
Silverdale Primary Care
Sound Health Care Center
Sound Integrated Health
Sound Pediatrics
St Joseph Pediatric
Swedish Primary Care Bainbridge
Taylor, Cynthia MD, MPH, FAAFP
The Doctors Clinic Port Orchard
The Doctors Clinic Poulsbo
The Doctors Clinic Ridgetop West
The Doctors Clinic Womens and Ch
The Manette Clinic
Tutihasi, Mimi MD
UWMC Pediatrics
Vancouver clinic
Vashon NeighborCare
Virginia Mason Bainbridge
Visual Connection
Vital Kids Medicine
WA HealthPlan Finder
Westsound Medical Clinic
Woodcreek Pediatrics
Dental Coverage
Combined Medicaid/CHIP
Medicaid
No Insurance
Other
Private Health Insurance
Dentist/Dental Home
Advantage Dental
Agape Dental Care
Arthur Dental Group
Atherton, David DDS
Bainbridge Kids Dentistry
Banks, Jessie DDS
Beck, Lyle DDS
Becker, Michael DDS (Bremerton)
Becker, Michael DDS (PO)
Best Dental Help
Block, Lisa DMD, MS
Bowman, Brian DDS
Bremerton Dental
Bright Now
Burien Family Dentistry
CK Family Dentistry
Clear Creek Dentistry
Current Dental
Dentistry for Children Bremerton
Dentistry For Children PO
Eagle Harbor Dental
Family Dental Associates
Fugaro, Orlando DDS MSD
Gibbons, John DMD
Gillespie, Kasey DDS
Harbor Kids' Teeth
Houpt, David DMD
Ihland Garden Dental
Kent Children's Dental Care
Kid's Dental
Kids Choice
Kids on 1st
Kitsap Gentle Dentistry
Kitsap Kids Dentistry
Legacy Dental
Lindquist Dental Bremerton
Little Pearls DesMoines
Little Pearls Kids Dentistry
Mayes, Amanda DDS
Morgan Family Dentistry
My Kid's Dentist
Neighborcare Rainier Beach
Odessa Brown Children's Clinic
Olympic Kids Dental
Ostheller, Joseph DDS
Pacific Ave Dental
Peninsula Community Health Svcs
Port Gamble S'Kallam Dental
Poulsbo Children's Dentistry
Redfern, Thomas DDS
Safe Harbor Smiles
Saturay, Kathleen DDS
Self, Shelly DDS
Shinn Kids Dental
Silverdale Dental Center
Silverdale Smiles
Smile Partners
Smiles 4 Kids 72nd St
Smiles4Kids Union Ave
taylor dental
Taylor Dental
The Kids Dentist
TLC Dental
WA HealthPlan Finder
Westside Dental
Willamette Dental Silverdale
Woodridge Dental
Does your child have a disability or do you have any concerns about your child's development?
Yes
No
Is there anything else you want to tell us about your child?
Location Preferences
Which program are you applying for? (Required)
2020-2021 Preschool Application
3-5 year preschool program
2020-2021 Program
3-5 year old full-day/ full year
Early Head Start 2020-2021
0-3 year application
1st Location Preference
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2nd Location Preference
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- Your Address
- Available Locations
Click a location on the map to see more info
Click here
to find a provider in your area.
Additional Applicant
Do you want to apply now for another child in your family?
Add Another Applicant
Siblings
Are there other children in the family?
Add a Sibling
Thank you for your application. We will be contacting you soon to complete the process. We will also send you an email with further instructions.
Required information is missing, see above.